Client Description. The client is a 19-year-old single male who was referred for treatment by his parents who are concerned that his use of alcohol is interfering with his grades in college. The client reportedly had all A grades in high school and had been placed in a program for gifted students. However, he has reportedly flunked out of college in his first year. Following this he was also recently arrested for his second DUI offense, the first offense occurring when he was a senior in high school.

According to his parents, the client was born at full term with no complications occurring in the pregnancy and delivery of the baby. He met all of his developmental milestones ahead of expectation and has experienced no major health issues although his last physical examination was several years ago. He excelled in school and was placed in a program for gifted and talented students. According to his parents the client maintained an A average throughout high school even while being in a more challenging gifted program. He went to college with ambitions to go into chemical engineering, but "flunked out" after his first year, an event totally uncharacteristic of his past. His father is a neurosurgeon and his mother is a research scientist. Family history is significant for anxiety disorders in his father and both grandfathers and possible alcohol abuse in both grandfathers.

In addition, the client and his parents report that he has a history of experiences of anxiety and worry present over a three-year period. His parents report he has always been "high strung," but that he began to display physical signs of anxiety such as (dizziness, palpitations, etc.), cognitive signs (a strong sense of worry over his everyday life issues), and behavioral signs (few social contacts, missing school, etc.) while in high school. The anxiety that the client experiences is not limited to specific or discrete situations and does not appear to consist of panic attacks (although this is also a consideration; American Psychiatric Association [APA], 2000). His parents described him as a "functional alcoholic" and that they were unsure if his drinking behaviors occurred before or after his difficulties with anxiety; however, they do know he was drinking alcohol regularly while he was in high school.

B. Assessment

The client's parents contacted the clinic for treatment for their son for his difficulties with suspected alcohol abuse. Both the client and the client's parents (with the permission of the client) participated in a standard clinical interview process designed to coincide with the diagnostic criteria from the DSM -- IV -- TR for axis I and axis II disorders.

The client agreed to enter treatment for issues with anxiety and substance abuse. Both the client and the therapist discussed the goals of treatment for the client. These included designing a program to manage the client's anxiety, attending AA meetings, and individual therapy and that helping the client control his anxiety and his use of alcohol. In addition, the client expressed a wish to return back to school and later sessions will be devoted to specific issues with college, anxiety, and methods of coping with the pressures of college designed specifically for the client.

C. Measurement.

The client underwent a clinical interview that investigated the presence of any DSM -- IV -- TR axis I or axis II disorders. In addition, the counselor plans to administer the Structural Clinical Interview for the DSM (SCID-1 and SCID-2; First, Spitzer, Gibbons, Williams, & Benjamin, 1996; First, Spitzer, Gibbons, & Williams, 1997) for further clarification and quantification of these issues. The SCID-1 and 2 are semi-structured clinical interviews to determine DSM diagnoses on axis I or axis II. The SCID for the new DSM-5 is not yet available, so the DSM-IV-TR was used in this case. In addition to this data a thorough and complete history will be taken regarding the onset of the client's drinking and onset of his difficulties with anxiety in order to determine as best as possible which one preceded the other. This information will be used to determine the focus of treatment (anxiety or substance abuse). The preliminary results of the clinical interview resulted in the following DSM -- IV -- TR diagnosis:

Axis I: 300.02. Generalized Anxiety Disorder

305.00. Alcohol Abuse

Axis II: V71.09. No diagnosis on Axis II

Axis III: No significant medical issues.

Axis IV: Two DUI arrests; flunked out of college; reports feeling isolated from friends and family.

AXIS V: GAF = 51-55. Symptoms of impaired social and interpersonal relationships. Alcohol Abuse. Severe symptoms of anxiety.

The client agreed to maintain a behavioral journal to document the daily instances where...

The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) will be used to monitor the client's level of anxiety over the weeks in treatment ad following treatment. This is a 21-question multiple-choice self-report inventory that measures the severity of an individual's anxiety (Beck et al., 1988). Likewise, the client will also maintain a journal of his drinking behavior in an effort to determine a baseline and to use as a barometer to judge the effectiveness of interventions aimed at his drinking.
D. Research Evaluation Design

The design of the study is a single -- case qualitative design. As there is only one client with these particular issues being studied this is believed to be the best possible research evaluation design for this particular issue. The questions in section 1.3 will be addressed as well as ascertaining whether the patient began drinking alcohol in high school in an effort to self-medicate for his anxiety or whether his anxiety worsened after he began drinking.

E. Intervention or Treatment.

One issue not yet discussed is the possibility that the client may have a medical condition (e.g., a cardiac condition) that is producing his anxiety. There are many medical conditions that can mimic anxiety disorders (Sadock & Sadock, 2007). The client has not had a full physical evaluation for several years and it would be prudent for the client to have such an evaluation.

In terms of treatment and cognitive behavioral psychotherapy (CBT) techniques have been demonstrated to be useful in treating anxiety and would be the first choice in this case followed by some insight-oriented techniques if it is discovered that there are developmental issues that contribute to his presentation (Covin, Ouimet, Seeds, & Dozois, 2008). This client can also be referred to a psychiatrist for medical management of his anxiety. Typically selective serotonin reuptake inhibitors, benzodiazepines, or other medications can be effectively used in clients who have generalized anxiety disorder (Sadock & Sadock, 2007). The combination of counseling/psychotherapy and medication can be an effective approach if indeed the client does have generalized anxiety disorder and not some physical problem that is producing or contributing to his anxiety and worry.

A number of problems, such as substance abuse, that are addressed in psychotherapy are related to lifestyle factors. Changing ingrained and nearly habitual behaviors can be quite difficult and require considerable effort and motivation on the part of the person who wishes or needs to change, such as a person that has developed a tendency to self-medicate anxiety with drinking alcohol. Traditionally physicians and even many psychotherapists encourage change through a combination of advice and insight, often using more direct forms of persuasion. The evidence that offering advice as a means to help a person change a detrimental behavior is not encouraging with only 5 to 10% success rates reported for traditional therapeutic modes for substance abuse or substance dependence (Rollnick, Kinnersley, & Stott, 1993). Using a direct method of advice opens the potential for clients to become even more resistance to changing potentially disruptive behaviors that have perceived subjective utility on part of the client (Rollnick, Kinnersley, & Stott, 1993). Motivational interviewing (MI) evolved from patient -- centered approaches to address this issue. Using MI combined with CBT would be an effective combination to address both the issues of alcohol abuse and anxiety (Rubak, Sandbaek, Lauritzen, & Christensen, 2005).

Finally, the client will be asked to attend a minimum of two meetings with local Alcoholics Anonymous (AA) groups. There is solid evidence that group therapy can be an important intervention for substance abuse and substance dependence and AA meetings, while are not empirically validated, can supplement individual counseling sessions for clients with substance abuse and comorbid psychological issues (Dutra, Stathopoulou, Basden, Leyro, Powers, & Otto, 2008).

F. Monitoring Progress and Post -- Intervention Data Collection.

Initial diagnostic considerations for the client will be confirmed using the SCID-1 and SCID-2. The BAI (Beck et al., 1988) as well as the client's daily anxiety journal can be used to monitor and record his progress in dealing with his anxiety is intervention continues. The client's journal will also be used to monitor his progress at reducing his intake of alcohol and the counselor will sent request that the client keep a record of his attendance and AA and present these attendance sheets during each session in order to monitor his…